CASE REPORTS
Between June of 1999 and December of 2000 six couples
were evaluated at our center for recurring adverse pregnancy outcomes
and positive group B streptococcus isolates from genital secretions.
They ranged in age from 29 to 37 and except for one (Patient 1)
all suffered from secondary infertility of two to five years� duration.
Patient 6 was an only child, the others all had siblings with live children.
Detailed histories did not reveal autoimmune disease, arthritis,
Raynaud�s phenomenon or thyroid condition in any of the couples. A
search for genetically abnormal offspring in any of the close or distant
relatives was negative. Patients 4 and 6 underwent complete genetic
testing with negative results. Patient 1 underwent a complex immunological
evaluation and during a failed pregnancy, prednisone, aspirin and heparin
were administered to counteract elevated killer cells. All five patients
who had suffered from secondary infertility had received multiple courses
of clomiphene citrate and four patients, at least during two cycles,
received Pergonal stimulation. One patient underwent a failed
IVF cycle.
Our evaluation, to determine the cause of the recurrent
abortions, included testing for the following conditions: structural
abnormalities were ruled out on all patients by hysterosalpingography.
In addition, three patients had hysteroscopy and laparoscopy with
negative findings. On cycle day three of the cycle all patients
underwent FSH, LH and Estradiol testing and a mid luteal phase endometrial
biopsy and serum Progesterone determination was performed to rule out
luteal phase defect. The results of these tests were all within
the normal range. All husbands had normal semen analyses. Seminal
fluid, vaginal, cervical and endometrial biopsy specimens were cultured
for Mycoplasma, aerobic, anaerobic bacteria and yeast. Syva Micro-Tract
system was used to identify Chlamydia trachomatis elementary bodies.
Table 1 summarizes the clinical
features of these patients, the culture findings, the therapy administered
and the clinical outcome.
The finding of group B streptococcus in cervical/endometrial
specimens was thecommon factor among all the women. The seminal
fluid of three husbands, patients 1, 2 and 5 exhibited the organism
at the time of the first testing. The results of the microbiological
studies and the subsequently administered antibiotic regimens are also
listed in Table 1. No further
therapeutic recommendations were made. Two to four months following
the completion of the antibiotic therapy all six patients reported spontaneous
pregnancies. Within ten days of the missed period, cervical specimens
were tested and found to be positive for group B streptococcus in all
six patients. Intravenous ampicillin therapy was initiated immediately
on all patients, 6 grams daily on five, while patient 2 received 2 grams
daily for ten days duration. A follow up cervical culture between
the 20th and 24th week of gestation remained positive for patients 1
and 2. These patients were prescribed Pen VK 250 mgs daily intermittently
for the remainder of the pregnancy. The total length of this oral
therapy for both patients was six weeks. Because of her previous
history of a mid trimester pregnancy loss, patient 1 underwent a Shirodkar
procedure, with removal at 38 wks followed by spontaneous rupture of
membranes and a normal vaginal delivery. All the other pregnancies were
managed expectantly and delivered at term. Patient 4 was delivered
by elective repeat Cesarean section at 39 weeks.
DISCUSSION
Factors determining the implantation of an intrauterine
pregnancy, the course of the pregnancy, events surrounding the delivery
and maternal and fetal complications during or after delivery are largely
unknown. There is, however, a growing body of evidence showing
that bacterial colonization of the genital tract is a significant factor
in certain instances of pregnancy loss and premature rupture of membranes
followed by premature delivery with maternal and fetal infectious complications.
We presented the case histories of six patients who all suffered
from a variety of pregnancy-related complications, including first trimester
pregnancy losses. The common feature in all the patients was a
group B streptococcal genital tract infection that persisted despite
an initial comprehensive antibiotic therapy. Though all patients
achieved spontaneous pregnancy within four months of the therapy, postconceptionally,
group B streptococcus was isolated from the cervical culture of all
patients and, in two, the colonization persisted even after the administration
of ten additional days of intravenous ampicillin therapy. Recently,
antibiotic resistance became a major concern in treating third trimester
group B streptococcal infections (7). We are unaware of studies
linking antibiotic resistance with pathogenicity, though prophylactic
antibiotic therapy is advocated for recurring second trimester group
B streptococcus chorioamnionitis (8). We suggest that asymptomatic
infection with group B streptococcus can affect the course of the pregnancy
in any trimester and a first trimester pregnancy loss can be an early
manifestation of the infection. Since asymptomatic group B streptococcus
carrier rate in the general population can vary as much as 5 to 40%
(2), there are no firm guidelines for the eradication or suppression
of this organism. Though the ideal dose of antibiotics and the length
of therapy are still debated, the benefit of prophylactic ampicillin
or penicillin during the third trimester is well documented in the literature
(9, 10). Since the only common variable distinguishing our studied
patients was the persisting group B streptococcal infection, we chose
a length of therapy and a dose of antibiotics well beyond the questionable
effectiveness. The persistence of group B streptococcus in two
of our treated patients however makes us wonder if any reasonable dose
could be recommended for the purpose of routine eradication of this
organism. The successful pregnancy outcome in these patients seems
to suggest suppression therapy as a viable alternative.
TABLE 1 (Requires
Adobe Acrobat)
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